JAMA: In a study that included more than 32,000 cases of melanoma among Medicare patients, approximately 1 in 5 experienced a delay of surgery that was longer than 1.5 months, and about 8 percent of patients waited longer than 3 months for surgery, according to an article published online by JAMA Dermatology. Melanoma is a leading cause of new cancer diagnoses in the United States, accounting for most skin cancerrelated deaths. Surgical excision is the primary therapy for melanoma. Surgical delay may result in the potential for increased illness and death from other malignant neoplasms, and may cause anxiety and stress.
No guidelines exist
regarding timely surgery for melanoma, although informal recommendations
suggest that melanomas should be excised within 4 to 6 weeks of
diagnostic biopsy. Population-based studies characterizing the delay of
surgery for melanoma in the United States have not been performed,
according to background information in the article.
Jason P. Lott, M.D., M.H.S., M.S.H.P., of the Yale University School
of Medicine, New Haven, Conn., and colleagues examined surgical delay
among Medicare beneficiaries diagnosed as having melanoma between
January 2000 and December 2009, using the Surveillance, Epidemiology,
and End Results-Medicare database. The researchers included all patients
undergoing surgical excision of melanoma diagnosed by means of results
of skin biopsy.
The study included 32,501 cases of melanoma; patients were more
likely to be 75 years or older (61 percent) and to have no prior
melanoma (94 percent). Of the total study population, 78 percent of
melanoma cases underwent excision within 1.5 months, 22.3 percent
underwent excision after 1.5 months, and 8.1 percent underwent excision
after 3 months. Surgical delay longer than 1.5 months was significantly
increased among patients 85 years or older compared with those younger
than 65 years, those with a prior melanoma, and those with more
co-existing medical conditions.
Melanomas that underwent biopsy and excision by dermatologists had
the lowest likelihood of delay; the highest likelihood of delay occurred
when the biopsy was performed by a nondermatologist and excised by a
primary care physician.
“Our results show that a delay of surgery for melanoma may be
relatively common among Medicare beneficiaries. Although no gold
standard exists to judge appropriate vs inappropriate surgical delay,
minimization of delay is an important patientcentered objective of
high-quality dermatologic care, especially given the potential harms of
psychological stress associated with untreated malignant neoplasms. Our
study highlights opportunities for quality improvement in dermatologic
care and suggests that efforts to minimize the delay of surgery for
melanoma might focus on increased access to dermatologic expertise and
enhanced coordination of care among different specialists,” the authors
(JAMA Dermatology. Published online April 8, 2015. doi:10.1001/jamadermatol.2015.119. Available pre-embargo to the media at http://media.jamanetwork.com.)
Please see the article for additional information, including other
authors, author contributions and affiliations, financial disclosures,
funding and support, etc.
Commentary: Timely Surgical Follow-up for Melanoma Among Medicare Beneficiaries
“Further research aimed at substantiating the consequences of
surgical delay in the setting of melanoma may also improve a movement
toward a standard of care and possible guidelines among all medical
subspecialties,” write Elaine Lin, B.S., a medical student at the School
of Medicine, Loma Linda University, Loma Linda, Calif., and Jerry D.
Brewer, M.D., of the Mayo Clinic, Rochester, Minn., in an accompanying
“In addition, medical training should emphasize heightened
communication skills and the importance of multidisciplinary teamwork as
an essential element to establishing solid surgical follow-up. Another
interesting, technologically savvy option could include a ‘Time to
Treat’ program integrated into the electronic medical records system to
aid in prompt intervention.”
(JAMA Dermatology. Published online April 8, 2015. doi:10.1001/jamadermatol.2015.0559. Available pre-embargo to the media at http://media.jamanetwork.com.)